Questionnaire for chemical burn patients in Zhejiang
I. Hospital————————————————— Admission No.—————————————————
II. Background information:
1. Name——————2. Gender: Male ( ) Female ( ) 3. Age: ————
4. Marriage status: Married ( ) Unmarried ( ) Divorced ( )
5. Education: Elementary school andbelow ( ) Junior high ( ) Senior high (including technical and secondary vocational schools) College and higher ( )
6. Employment: Part-time ( ) Full-time ( ) Others:——————
7. Length of employment till the time of injury: ———years———months———days
8. Location of injury: production shop ( ) laboratory ( ) transportation ( ) during handling of the substance( ) Others——————
9. Name of the employer: ———————————— Employer affiliation: State-owned ( ) Foreign-owned or joint venture ( ) Private ( ) Others ——————
10. Cause of injury: (1) Equipment problems (such as aged parts or insufficient technique) ( ) (2) Inappropriate operation ( ) (3) Suicide ( ) (4) Intended assaults( ) (5) Others ——————
11. Date of burn injury: ———year———month———day
12. Time of admission: ———days———hours after injury
13. Length of hospital stay: ———days
III. Description of injury
1. Name of the causative substance—————————————
2. Area of burn ——————BSA%, among which superficial II-degree burn —————, deep II-degree burn —————, III-degree burn —————, and IV-degree burn —————.
3. Injured body parts: Head and face, neck, front trunk, rear trunk, arm, forearm, hand, hip, perineum, lower extremity.
4. Concomitant injury: (1) Inhalation injury: none ( ) mild ( ) moderate ( ) severe ( )
(2) Chemical poisoning: none ( ) mild ( ) moderate ( ) severe ( )
5. Surgical treatment: Yes ( ) No ( )
6. Outcome: Healed ( ) Improved ( ) Transferred ( ) Discharged against advice ( ) Death ( )
IV. Onsite wound management:
1. Was the patient aware that the wound should be immediately treated onsite? Yes ( ) No ( )
2. Was the wound immediately treated onsite? Yes ( ) No ( )
3. Management method: (1) Irrigate with massive water ( ), irrigation time: ———minutes. Irrigation started at ———minutes after injury.
(2) Apply neutralizers ( ) (3) Others ———————
V. Training on related know-how and use of protective gears
1. Had the patient received orientation training before work: Yes ( ) No ( ) training time: ———months———days
2. Did the workplace provide protective gears? Yes ( ) No ( ) Don’t know ( )
3. Was the patient wearing protective gears at the time of injury? Yes ( ) No ( ) Yes, but failed to meet the requirements ( )
4. The patient thought protective gears were: Necessary ( ) Necessary but inconvenient ( ) Unimportant ( )
VI. Availability and use of emergency shower and first-aid facilities
1. Was onsite emergency shower available? Yes ( ) No ( ) Don’t know ( )
2. Was the equipment functioning? Yes ( ) No ( )
3. Was the equipment easy to use? Yes ( ) No ( )
4. Availability of first-aid facilities:
(1) First-aid station was established ( ), (2) emergency medicine could be found ( ), (3) neither was available ( )
Date of filling the form —————————— Person filling the form ——————————